Healthcare Provider Details

I. General information

NPI: 1720775117
Provider Name (Legal Business Name): JOSHUA GREEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 N MAIN STREET EXT STE 2A2
WALLINGFORD CT
06492-2483
US

IV. Provider business mailing address

850 N MAIN STREET EXT STE 2A2
WALLINGFORD CT
06492-2483
US

V. Phone/Fax

Practice location:
  • Phone: 203-626-5581
  • Fax:
Mailing address:
  • Phone: 203-626-5581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number001203
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: